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Print this form and send it with your order to 328 Swanston Street, Melbourne 3000.
MASTERCARD [ ] BANKCARD [ ] VISA [ ]
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CARD NUMBER _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
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CARD HOLDER'S NAME
________________________________________________________________
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ADDRESS
________________________________________________________________
CITY
___________________________________ POSTCODE ____________
COUNTRY___________________________________________ |
EXPIRY DATE _ _ / _ _ TOTAL AMOUNT ___________________ |
I authorise the State Library of Victoria to debit my credit card with the amount shown above. I certify that I am over 18 years of age.
SIGNATURE __________________________________________________ |
